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A comparison of three different strategies to treat partners of men with urethritis Patty Kissinger 1 Gwangi Richardson-Alston 1 Jami S Leichliter 4 Hamish Mohammed 1 Stephanie N Taylor 2,3 David H Martin 2 Thomas A Farley 1 1 Tulane University School of Public Health and Tropical Medicine

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a comparison of three different strategies to treat partners of men with urethritis

A comparison of three different strategies to treat partners of men with urethritis

Patty Kissinger1

Gwangi Richardson-Alston1

Jami S Leichliter4

Hamish Mohammed1

Stephanie N Taylor2,3

David H Martin2

Thomas A Farley1

1Tulane University School of Public Health and Tropical Medicine

2Louisiana State University Health Sciences Center

3New Orleans Health Department Delgado STD/HIV Clinic

4 Centers for Disease Control and Prevention

background
Background:
  • Studies of Chlamydia trachomatis among women demonstrate that only 25-40% of named male partners were treated
  • Alternative methods of partner treatment are needed
  • Evidence that patient-delivered partner medicine (PDPM) is superior to partner referral (PR) for reducing STI recurrence is mounting, but not yet definitive
  • Less is known about patient-delivered partner medicine among men
slide4

Studies with biological outcomes either absent or not demonstrating statistical significance

objectives
Objectives
  • To compare patient-delivered partner medication (PDPM) with booklet enhanced partner referral (BR) and standard partner referral methods (PR) among men with urethritis
  • Outcomes were:
    • Percentage of partners who told their partners they took the medicine (per index man’s report)
    • Re-infection by CT or GC
the interventions
The interventions
  • Standard partner referral (PR) – men were told to tell their partners to go to either the public STD clinic or the clinic of their choice for STI testing and treatment
  • Booklet-enhanced partner referral (BR) – men were given a booklet which contained 4 tear out cards with information for the partner and the provider for partner treatment
  • Patient delivered partner medication (PDPM) - azithromycin 1 gram/cefixime 400 mg or ciprofloxacin 500 mg with instructions, warnings and a nurse pager number
inclusion
Inclusion
  • Inclusion criteria:
    • Men who attended the Delgado public STD Clinic in New Orleans
    • 16 years of age or older
    • With a presumptive diagnosis of urethritis
    • Between 1/02 and 12/03
    • Who had at least one or more female sex partner(s)
    • Whose partner(s) did not accompany them to the clinic
    • Were treated for gonorrhea and/or chlamydia at baseline and had not taken cefixime, ciprofloxacin or azithromycin in last two weeks prior to baseline
    • Provided informed consent to be re-contacted by telephone or in person in 14-28 days for a follow-up interview
    • 85.1% accepted to participate
methods
Methods
  • Intervention allocation was randomly assigned by month rather than by individual
  • Information about each partner was elicited from the index men at baseline and one-month using a audio computer-assisted self-administered interview (ACASI)
  • Genprobe urethral swabs were performed at baseline and PCR urine testing and/or Genprobe urethral swabs were performed at one month
  • Men were given $10-$40 for follow-up visits
  • IRB approval was obtained from Tulane, Office Of Public Health, the N. O. Health Dept. Research Review Committee and CDC
results
Results
  • 887 men reported information on 1808 partners at baseline
  • Men were mostly:
    • African American (96.2%)
    • > 24 years of age (55.8%)
    • Had < high school education (78.1%)
    • Had > 2 partners (68.1%)
    • 97.7% of partners were women
    • Had dysuria/discharge at baseline (85.9%)
    • Baseline GenProbe test positive (N=760)
      • GC 61.6%
      • CT 19.6%
      • Either CT or GC 69.3%
      • CT and GC 6.1%
outcomes
Outcomes
  • Of 887 men enrolled:
    • 84.1% completed a follow-up interview
    • 31.6% provided a follow-up STI test
    • Information was reported on 1313 partners at follow-up
  • Of 280 who provided follow-up STD tests:
    • 25.9% had CT or GC
      • 17.6% had CT
      • 12.4% had GC
    • 25% had symptoms at follow-up
outcomes12
Outcomes
  • Of 1313 partnerships reported on at follow-up, index men reported that:
    • 55.8% of indexes talked to the partner about the STI
    • 58.9% of indexes gave the intervention to the partner
    • 44.9% of the partners took the medicine
    • 35.7% saw them take the medicine
    • 27.0% had unprotected sex before the partner took medicine
    • 51.6% used condoms all the time during follow-up
    • 36.8% re-initiated sex with the partner
    • 13.1% of index men acquired a new partner
characteristics associated with index report of partner taking medicine n 1313
Characteristics associated with index report of partner taking medicine (N=1313)

* P < 0.05, **P < 0.001

slide17

Multivariable GEE results of factors associated with index report of partner taking medicine (N=1313)

* P < 0.05, **P < 0.001

characteristics associated with a ct or gc positive urine test at one month follow up n 280
Characteristics associated with a CT or GC positive urine test at one-month follow-up (N=280)

* P < 0.05, **P < 0.001

discussion
Discussion
  • Randomization worked well
  • Very large sample size
  • No partner side effects were reported
  • PDPM consistently better than PR for all outcomes
  • Biological outcome: while we had high follow-up rates for interviews, many men refused to give urine specimens. But those who gave urines were similar to those who did not
characteristics of those followed and those who gave urine
Characteristics of those followed and those who gave urine
  • Those who were LTF (n=138) were more likely than those who were followed (n=729) to be:
    • < 24 years of age (54.3% vs. 41.9%, P < 0.01)
    • to have > 2 partners (74.6% vs. 66.8%, P < 0.07)
  • They were similar by race, education and symptoms at baseline
  • Among those who were followed, those who gave a urine test (n=213) were similar to those who did not (n=516) by race, education, age, symptoms at baseline and number of partners
conclusion
Conclusion
  • In men, PDPM was better than both BR and PR in treatment of partners and for the prevention of recurrence of CT or GC.
implications
Implications:
  • PDPM and BR can be useful public health interventions to prevent the spread STDs among men.